DC Psych Residents,

 

The article below has stirred deep, relevant discussion in our psychiatry community. (The APA Assembly listserv is explosively active.) I have strong opinions about it and feel confident you will as well. Please don't hesitate to post your thoughts. 

 

Hind

 

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Twenty-First Century Ethical Challenges for Psychology

Gerald P. Koocher

July-August 2007 ? American Psychologist 375

Vol. 62, No. 5, 375-384

[ extract only]

Witnessing the Demise of Psychiatry

The specialty of psychiatry has long stood at the lowest rung of the medical
hierarchy ladder in terms of both scientific prestige, professional
recognition, and institutional authority within medical institutions. Recent
developments in psychiatric practice have accelerated a decline in the
profession, and psychologists should take note of the key contributory
factors and learn. As he ended his term as president of the American
Psychiatric Association in May 2006, Steven Sharfstein addressed the issue
of prescribing privileges for psychologists and told his colleagues,

"But let's be quite clear about the terrain of prescriptions. Most of the
prescribing of psychotropic medications has been dominated by general
physicians who do the bulk of prescribing, estimated at more than 75 percent
of all prescriptions for psychiatric medications in the U.S. . . .Of greater
concern for psychiatry is the domination of treatment of mental illness by
psychopharmacologic means and the attrition of psychotherapeutic and
psychosocial approaches in our practice. Psychopharmacology ascendance in
practice has been driven by managed care protocols, which deemphasize the
psychotherapeutic skills of psychiatrists and puts [sic] a premium on very
short-term hospital care, medication management, and reevaluation of
diagnosis and treatment."

Sharfstein's (2006) remarks highlight the predictable demise of psychiatry
as a profession over the next several decades. As psychologists, we already
knew that the training model in psychiatry (i.e., newly minted physicians
with a minimal background in psychiatry get hospital-based on-the-job
training in psychopathology, psychotherapy, and psychopharmacology after
leaving the academy) could not compete effectively with the focused study of
these topics and many others in a context of behavioral science research, as
delivered in psychology doctoral programs. As the above quote by Sharfstein
indicates, most physicians in the United States do not rely on psychiatrists
for prescribing advice and have not done so for many years. At the same
time, psychopharmacology has become the focus of most psychiatry residency
training, to the exclusion of psychotherapy and psychosocial interventions.
Advances in psychopharmacology and the demonstrated effectiveness of
prescribing psychologists with appropriate postdoctoral training signal the
end to any claims of uniqueness or incremental quality on the part of
medical providers trained in the traditional psychiatric model.

A highly respected academic psychiatrist (Gabbard, 2005) has noted that he
frequently encounters psychiatric residents who claim that they have no
interest in psychotherapy and therefore see no point in attending seminars
on the subject or meeting with a psychotherapy supervisor for one-to-one
instruction. He hardly stands alone in noting the increasing disinterest of
psychiatrists in the practice of psychotherapy (Detre, 1987; Reist &
VandeCreek, 2004; Stedman, 2006; Winston, Been, & Serby, 2005). Gabbard
(2005) went on to implore his colleagues to improve their teaching, citing
as one key point the need to avoid teaching theory with clinical examples.
Rather, he suggested teaching the practice of psychotherapy as a series of
hypotheses that are repeatedly tested and that are altered again and again.
He acknowledged that practitioners will make occasional errors and that they
should avoid "worship at the altar of evidence-based therapies" (p. 336).
While Gabbard's recommendations reflect a certain wisdom, they also
highlight the very different background and inherent inadequacies physicians
bring to the practice of psychotherapy, when contrasted with graduate
psychology curricula and clinical training.

Recent medical school graduates already recognize the issues. Moran (2006)
reported that according to the National Resident Matching Program, a total
of 983 medical school graduates entered PGY-1 (i.e., Post Graduate Year 1,
or the first year out of medical school) general psychiatry residency
programs in July 2006. Of those, only 643 (65%) had graduated from U.S.
medical schools, a 2% decline from the class entering psychiatry residencies
in 2005. These numbers represent a leveling off of U.S. medical student
interest in psychiatry after very slow growth between 2000 and 2005.
Psychiatric residencies no longer hold much attraction for the best and
brightest young physicians interested in brain functions and their
relationship to mental health. The best young physicians with such interests
increasingly seek additional doctoral degrees and specialization in clinical
neuroscience.

As psychologists with postdoctoral credentials in psychopharmacology grow in
numbers, and the aging population of baby-boomer psychiatrists retires,
psychiatry will disappear as a medical specialty. The hazard facing
psychologists will involve avoiding the pitfalls that twentieth century
psychiatry ignored. We must guard against potential loss of competence in
the skills that have traditionally offered our clients incremental value:
our scientific foundations in assessment, psychotherapy, and other
nonmedical interventions. Reaching for a prescription pad is easier than
conducting a well-founded assessment and expert psychotherapy. The demands
of the marketplace may make it more lucrative to prescribe than to talk.

Prescribing psychologists will also begin to face other ethical hazards,
including those related to commercial pharmaceutical sponsorship. I hope
that we will learn by having observed our physician colleagues struggle with
such issues. We will also have to remain aware of selfmedication hazards.
Studies suggest that physicians, while less likely than their age and gender
counterparts to have used cigarettes and illicit substances (e.g., such as
marijuana, cocaine, and heroin) in the past year, were more likely to have
used alcohol and two types of prescription medications-minor opiates and
benzodiazepine tranquilizers (Hughes et al., 1992). Richard F. Corlin, the
2002 president of the American Medical Association, has stated, "The drug
physicians are most likely to get addicted to is not cocaine or heroin-but
hydrocodone. A common prescription pain killer"
(http://www.ama-assn.org/ama/pub/ article/2542- 6121.html). As we gain new
skills, we must not allow other skills to atrophy or allow ourselves to fall
prey to the hazards of those who have gone before us.

Recommendations in Preparation for the Demise of Psychiatry

We can learn several lessons by watching the recent evolution of psychiatry
as a profession and use these lessons to advance the public welfare. First,
we should actively differentiate ourselves from psychiatry, giving
particular emphasis to the research and science that underpin our
interventions and to the depth and breadth of our preparation for practice.
For example, when psychiatrists point to medical school as preparation, we
should highlight the inadequacy of medical school and residency training for
scientific psychodiagnostic and psychotherapeutic practice. Second, we
should continue to promote excellence in behavioral neuroscience as a
psychological specialty. Third, we should move forward with well-grounded
education and training for expanded practice, such as prescription
privileges. However, we should do so with full caution learned by observing
psychiatry's failings in these areas. For example, we should not forget the
practice of psychotherapy by too often reaching first for the prescription
pad; we should avoid the slippery slope of pharmaceutical industry
seductions; and we must remain mindful that the authority to prescribe also
includes the authority to unprescribe inappropriately or unscientifically
ordered medications. Fourth, we must update our licensing standards to move
key competence assessment and examinations to the predoctoral level, so that
our graduates stand ready to enter practice upon graduation with a terminal
degree, as is the case with our sister professions (e.g., medicine, nursing,
and social work). Finally, we must encourage our colleagues who specialize
to achieve board certification from rigorous organizations recognized by the
APA.